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Printed Date: 9/22/2015
Medicare can make payment for Positive Airway Pressure (PAP) devices and related accessories when the patient's medical record shows the patient has Obstructive Sleep Apnea (OSA) and meets medical documentation, test results, and health conditions as specified in the CMS Internet-Only Manual (IOM) Publication 100-03, Section 240.4 (PDF, 1,022.22 KB) and the Durable Medical Equipment (DME) Local Coverage Determination (LCD) L33718.
Medicare's coverage for PAP devices and accessories begins with a 12-week trial period. In order for a DME supplier to provide the PAP device, the following must take place:
The preceding steps will allow the DME supplier to bill Medicare for three rental months of the PAP device and related accessories.
Between the 31st and 91st day after initiating PAP therapy, your medical record documentation must show a face-to-face re-evaluation with your patient to assess the benefit of PAP therapy. You should review how symptoms of OSA have decreased and how the PAP device has helped your patient. Your medical record documentation must also demonstrate the patient is adhering to the therapy and that you have reviewed this adherence.
Adherence to therapy is defined as usage of the PAP device greater than or equal to four hours per night on 70 percent of nights during a consecutive 30-day period any time during the first three months of initial usage. Documentation of the patient's adherence to PAP therapy can be accomplished by your review of information maintained on the PAP device via visual inspection, data downloaded from the PAP device, or access from web-based sites with data transmitted from the PAP device. This information must be maintained in your patient's medical records and made available upon request.
The face-to-face re-evaluation does not have to be completed by the medical professional who ordered the PAP device. It can be completed by another physician or nonphysician practitioner following the patient. For example, if a sleep specialist ordered the PAP device, but the patient goes to their primary care physician two months later, that would be acceptable and meet the Medicare requirement for the re-evaluation.
The standard written order (SWO) for the PAP device must contain the following:
The DME supplier will most likely send you a standard written order that lists all of the PAP accessories that can be billed to Medicare. Please review, sign and date that SWO in a timely manner so the DME supplier can file claims to the Medicare program.
Following these coverage guidelines will help your patients and the Medicare program by verifying that there is medical documentation to support the provision of a PAP device and allow your patient to receive the therapy needed to treat OSA. Your assistance will allow Medicare to pay claims appropriately and ensure that your patient receives the DMEPOS items you have prescribed.
For coverage and limitations of these supplies review Local Coverage Determination (LCD) L33718, Policy Articles A52467 and CMS Local Coverage Article A55426.
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Last Updated: 08/31/2020